Measuring Lingual Range of Motion

For so long, we have focused on lingual strength and range-of-motion.

The Iowa Oral Performance Instrument (IOPI),  the SwallowStrong and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.

We finally have a measurement scale for lingual range of motion.

C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken.  Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients.  Dysphagia (2014) 29:489-499.

This study compared results in treated surgical patients vs. healthy patients.   36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.

The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.

The scale was made to define lingual deficits.  This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.

Lingual protrusion was measured using the Therabite jaw range-of-motion measurement discs.

Protrusion Scores:  (100) Normal:  > or = 15 mm past the upper lip margin

(50)   Mild-mod:  >1mm but <15mm pasat the upper lip margin

(25)   Severe:  Some movement but unable to reach upper lip margin

(0)     Total:  No movement

Lateralization Scores:  based on ability of the tongue to touch the commissures of the mouth.  Measure both right and left side.
(100)  Normal:                      able to fully touch the corner of the mouth.
(50)    Mild-Moderate:  50% reduction of movement to corner of the mouth                                                in either direction.
(25)    Severe:  >50%           reduction in movement.
(0)      Total:                          No movement.

Elevation Scores:    

(100)  Normal:  complete tongue tip contact with the upper alvoelar                                       ridge.
(50)    Moderate:  tongue tip elevation but no contact with the upper                                       alvoelar ridge.
(0)      Severe:  No visible tongue tip elevation

Total Scores were assigned by adding the protrusion score+ right lateralization score + left lateralization score + elevation score divided by 4.

Scores were 0-100:      

0=severely impaired/totally impaired
25=Severly impaired
50=mild-moderate impairment
100=normal

During this study, tongue strength was measured using the Iowa Oral Performance Instrument.

Jaw range-of-motion was measure using the Therabite jaw range-of-motion measurement discs.

Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4×4 piece of gauze for 2 minutes then spit the gauze in a cup.  The gauze was weighed before and after mastication.

The Performance Status Scale was used to determine diet type, speech uderstandability, impact of surgery on ability to eat socially.

Quality of Life was measured using the Eating Assessment Tool-10 (EAT-10), MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI).

The study found that lingual range-of-motion can negatively affect all aspects of a patient’s life and correlates with performance and quality of life.

Cranial Nerves: App Review

App:  Cranial Nerves:  Pocket Clinical Resource

Price:  $2.99

What it is:  An incredibly simple app to use to learn and look up information on cranial nerves.

System:  iOS (iPhone and iPad)

Version:  1.2.4

Let me start off by saying:  I LOVE THIS APP!

I was referenced to a cranial nerve app which was $60.  I thought to myself there has to be a less expensive version that I can utilize just as easily.

I found the app!

We’re told often to complete a cranial nerve assessment, especially looking at neuro patients including CVA and patients with dysphagia.

Cranial nerves can be daunting and scary.  They don’t have to be!

Along the left side of your iPad (for that version of the app), you have a list of the nerves by roman numeral.  Touch the roman numeral corresponding to the cranial nerve you are trying to find.

You will find a full description of that nerve:  function, nerve tract, integrity tests, symptoms and signs and images.

Yes!  This app will tell you how to test the nerve and symptoms signs if the nerve is not intact.

Sometimes there just is not enough information.  If you are a Google/Wikipedia fan like me, then this app was designed for you.  You might notice at the top of the description of the nerve in the above picture, there is a box icon, a G icon, a globe icon and a picture icon.  If you have internet access, touch the G icon.  Amazingly you will be directed to a Google search of that nerve.  Similarly, touch the globe icon (third from the left) and you will be directed to a Wikipedia search of that nerve.

This app can be used as a learning tool and a quick reference when you just can’t remember what that nerve is for or how to test it!

This is a 5-star app in my book!

Dysphagia Assessment

So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely seen people do a thorough dysphagia bedside evaluation.

 I’m trying to standardize the manner in which I complete my bedside evaluation. I have started using the SOPE, the MASA and the Sage during every assessment, along with a thorough chart review and assessing aspiration risk factors. I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The Sage assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia from my standpoint. I also do the traditional feel for laryngeal elevation, but I also feel for hyoid protraction. I have started assessing with water and graham crackers. If I need to, I will thicken the liquids, but usually wait for an instrumental assessment. I also have started using the 3 ounce water swallow challenge, which has been a good indicator for aspiration from what I have done so far.

 It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat. Another point that has been drilled into my head is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the amount of output in the muscle functions. Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Sensory input can also be established through tactile, thermal, or NMES input. In fact, Vitalstim placement 1 has the highest sensory input of all the Vitalstim placements. DPNS is highly driven by sensory input to the cranial nerves through use of frozen lemon swabs, along with thermal, tactile stimulation (TTS).

 You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for Frazier Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.

 It is vital to assess motoric function. You treat the motor dysfunction, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment. There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal sqeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. I am extremely excited about the MBSImP which will be published next year with certification courses to follow!!

 The 3 ounce water swallow challenge is fairly new. It is an indicator of aspiration as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. With this challenge, the person is given 3 ounces of water, either by straw or cup sip. They drink the water continuously. Any coughing, throat clearing or inability to drink all 3 ounces at one time is considered a fail. If the person can continuously drink the water and not cough during or for a minute after the challenge, they pass. Those that fail are then assessed instrumentally.

 Watching a person eat is also very critical to the evaluation. One predictor of aspiration is inability to self-feed. Medication can often affect a person’s ability to swallow, affect amount of saliva a person has to help break-down the food orally or affect the person’s alertness.

 A thorough dysphagia exam is vital and necessary for treatment. A good bedside examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

Put Yourself in Their Shoes

My number one rule-of-thumb, especially when treating my dysphagic patients is to put myself in their shoes.

 First, I need to make this patient and their family member understand just what is going on. No, I don’t explain dysphagia in medical terms, but it is easy to put into layman’s terms when you understand the swallowing process. The patient needs to understand dysphagia, what is compromising their swallowing function and understand how and why dysphagia treatment will make them better and safer. Patients need to understand that this can be a life-threatening dysfunction but that it can be improved through therapy, diet modifications, compensations, etc.

 I also have to remember that one of the joys in life is eating. We all go through our day eating and drinking. It’s how we socialize, what we do at holidays. Our patients do not want to continue on a pureed diet with honey thick liquids when there is therapy available to possibly get them to a higher level. I’ve seen too many people discharged from therapy on an altered diet because the therapist has no idea what to do with them. I’ve also seen patients upgraded before they even really have therapy. Upgraded three days after the MBSS with severe dysphagia and aspiration is not an appropriate upgrade.

 Remember that our job as dysphagia therapists is to rehabilitate, or bring about change to the swallowing system and the musculature of the swallowing system. We cannot bring about change by sitting with a patient during lunch and reminding them to tuck their chin. We cannot bring about a change by having them stick out their tongue 30 times a day and think that’s going to improve the swallow. The only true exercise for the swallowing system is swallowing and challenging the patient with the swallow.

Exercise

Recent and some previous dysphagia literature emphasizes the use of exercise physiology. Researchers such Lazarus et. al, Robbins et.al, Burkhead et. al and Clark have published the need for incorporating exercise physiology into dysphagia therapy. They emphasize the need to understand the muscles involved in the swallowing mechanism, understand their function so that you can exercise those muscles in the manner in which they function for the swallow.

 The best way to work and improve the swallowing function is to swallow. Not only simply swallow, but push the swallow beyond it’s normal capacity. One way to incorporate increasing the load of the swallow is to use the effortful swallow, the masako or the Mendelsohn maneuver. The Shaker is a great load-resistant exercise to increase opening of the UES. These exercises have been researched and shown to be effective. Logmemann credits the research that has been established for the Shaker exercise and the lingual strengthening exercises from Robbins to increase lingual strength, with overall strengthening of the swallow.

 I’ve started an exercise approach to my dysphagia therapy. I started using almost like a “circuit” of swallowing training. I give the patient a list of exercises to complete while in therapy. Depending on what they need to focus their therapy, they complete a circuit of exercises. I use a variety of swallowing exercises including the Mendelsohn maneuver, effortful swallow, lingual resistance exercises, oral manipulation exercises. Most exercises include swallowing as part of the exericise. One of my favorite strengthening exercises is sucking pudding through a straw. I have the patient start with a regular drinking straw and work their way down to using a coffee stirrer. This not only strengthens the tongue, cheeks and lips, it also requires that they swallow. They spend x number of minutes of each exercise.

 Taking an exercise-based approach to swallowing is far superior to simply altering diet consistencies or adding compensatory strategies to each swallow. Rehabilitation should bring about a change to the swallow mechanism. I do not nor will I use compensations or altered diets in my therapy. I may put the patient on an altered diet, but I want to work the system naturally, not with a compensation if I can avoid it! Look to your PT and OT departments. They work the muscles to bring about change and we should be doing the same.

 Logemann, J.A. (2005). The Role of Exercise Programs for Dysphagia Patients. Dysphagia. 20: 139-140.

 Clark, H.M. (2005). Therapeutic exercise in dysphagic manamgent: Philosophies, practices and challenges. Perspectives in Swallowing and Swallowing Disorders, 24-27.

 Robbins, J.A, Butler, S.G, Daniels S.K., Diez Gross, R., Langmore, S., Lazarus C.L., et al (2008). Swallowing adn dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51: S276-S300.

 Burkhead, L.M., Sapienza, C.M., Rosenbek, J.C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia, 22:251-265.

 Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12: 400-415.

 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L. and Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 52, 1483-1489.

 Lazarus, C., Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrice et Logopaedica, 55, 199-205.

NSOMES-To Use Them or Not to Use Them…..That is the Debate

This topic may seem a little off the dysphagia path, but it’s not, trust me.  I have actually thought a lot about NSOMES in my therapy as of late.  Not only does NSOME, at least in my eyes, stand for Non-Speech Oral Motor Exercises, I also use the term for Non SWALLOWING Oral Motor Exercises.  This was the March topic for the SLP Chat, which was a very interesting conversation.  I also went to a session on NSOME’s at our state convention, which actually turned into an artic course using core vocabulary which upset me immensely since I was hoping to learn a little more about NSOME’s.

 

 

First, let’s start with these exercises.  What are they?  Non-speech (swallowing) imply that these are movements that are not concurrent with producing sounds or swallows.  These are the typical stick out your tongue 10 times, move your tongue from corner to corner of your mouth.  These are actions that we use to “strengthen” the speech/swallowing mechanism by having our patients move the articulators.

 Now I’m switching to all swallowing-hey that’s what my blog is about.  It’s my blog!!  So, anyway, who hasn’t been to a facility and observed the SLP there.  What do they usually do for swallowing exercises.  Stick out your tongue, try to touch your nose with your tongue, move your tongue from corner to corner of your mouth, stick out your jaw…….all of these 10 times, 3 times a day.  So, 30 times total.  How many of these patients truly get better with only these exercises??  In my experience, very few.

 Robbins, et al wrote a very good article about neural plasticity in swallowing.  I actually reviewed that article in an earlier blog.  One principle is that plasticity is experience specific, or that to make neural changes (i.e. to the swallowing mechanism) the experience has to be specific to the actual movement.  So, to improve the swallowing mechanism, you have to practice swallowing.  To make neural changes to the swallowing system, the patient has to SWALLOW!  What a novel idea.

 Dysphagia therapy is quickly moving to a very exercise-based therapy.  No, not the typical stick out your tongue exercises.  When you exercise the swallowing system, there are very few researched techniques, however they do exist.  With all the changes in therapy and in insurance, healthcare, now is most definitely the time to move to evidence-based practice, if you haven’t already jumped on board.  I have my list of exercises that I use that are swallowing-specific and have evidence to support them.

 Tongue exercises using resistance, i.e. tongue depressor or IOPI.  Robbins et al looked at the IOPI 10x/3xday against the tongue tip, blade and dorsum with improvement with swallowing.  (Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., &amp; Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.)  Lazarus, et al looked at the IOPI vs. a tongue depressor and found that the tongue depressor exercises worked just as well as the IOPI exercises.  (Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normalsFolia Phoniatrica et Logopaedica, 55, 199-205.)  So, I have my patients use a tongue depressor and push their tongue against it using protraction, elevation, depression and lateralization, 10x each, 5x/day, 5 days/week.

 

 

 

 Mendelsohn Maneuver uses resistance with swallowing.  You can continually add resistance if you have the capability to use sEMG with your patients, which unfortunately I do not have at this time.  With the Mendelsohn, you not only have resistance, but the entire exercise involves the act of swallowing, therefore it is a relevant exercise to improve the swallow.  (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence.   Journal of Speech, Language, and Hearing Research, 51, S276-300.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.) 

The Masako technique is a little bit questionable with therapy.  Yes, it does involve a swallow, however, how often do you swallow with your tongue sticking out???  This exercise should be used with caution, and should never be the only exercise you use, but may be a good exercise paired with another exercise to improve tongue base retraction.  So, possibly have the patient use the Masako and then the Mendelsohn??   (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence.   Journal of Speech, Language, and Hearing Research, 51, S276-300.)

 The Shaker exercise offers not only resistance using the head as weight, but repetition of the exercise.  Logemann and Eastering both have research for the Shaker exercise available, however use caution with this exercise, particularly for cardiac patients.  I have been to a conference where I learned the Neckline Slimmer (https://www.buynecklineslimmer.com/) using the highest resistance spring can do the same as the Shaker without the strain on the patient.  However, be careful with this as there is no research out there to support this.  The Slimmer can be purchased at many stores including Walgreens and Bed Bath and Beyond.

 The effortful swallow uses an actual swallow with the added resistance by producing force with the swallow.  You have to have the patient not only “swallow hard” but an important component of the effortful swallow is to forcefully push the tongue against the palate, therefore creating pressure for the swallow.  (Bulow, M., Olsson, R. &amp; Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.)  (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence.   Journal of Speech, Language, and Hearing Research, 51, S276-300.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.)

 There are also exercises that I use that are “swallowing-based” such as changing the consistency, texture, weight of the bolus, one of my favorite exercises (you’d know this if you read my previous blog posts) is having the patient suck pudding through a straw and then change to a smaller straw as the patient progress.  This not only has the person swallow but strengthens the oral phase of the swallow through sucking, which is a natural motion of swallowing (we all use a straw at some point).  Mastication exercises are good, if the patient is not appropriate for an actual bolus, I use a mesh baby feeder or cheese cloth.  Any exercise you can have the patient complete that adds resistance or complication to their natural swallow is what we need.  Remember, evidence-based can also be what YOU trial, track and possibly research.  

 Now, there are times that I do use NSOME’s, I know, right, gasp.  I find that STRETCHING the articulators/swallowing mechanism is quite good for patients that have been through radiation therapy, for example.  If they are unable to move the articulators to the maximum benefit, yes, I will combine oral stretches/massage/myofascial release to the mix (above exercises) for maximum benefit.

 

 Will tongue exercises, jaw exercises, etc work outside of the context of swallowing/speech, I really don’t think they will.  You have to train the muscles to do what they’re supposed to do for function.  To do that, you HAVE to combine exercise/therapy with the intended movement.  You cannot rehabilitate speech without using speech and you cannot rehabilitate swallowing without having your patient swallow, even if it is only their own secretions.  Make certain that what you are doing is working for your patient, if the tongue exercises don’t seem to be changing anything, by the data you track, change what you are doing!  We are therapists adn are trained to use a variety of techniques.  If you are uncertain about where to go next, ask.  Don’t be afraid to ask questions.  

 When having your patients exercise, whether it be the speech or swallowing system, look to your physical therapist for ideas.  They exercise their patients, however they relate the exercise to the actual act (i.e. walking) and combine the exercises with the act of walking.  They don’t have their patients do leg exercises and send them home expecting them to walk with more efficiency.  They also exercise their patients with walking and make it more difficult (without the walker).  

 Remember when using Swallowing Oral Motor Exercises, use plenty of repetition, add resistance and make it worth your and your patient’s time!

 

 

The Dummies Guide to Dysphagia

A big shout-out to Tanya for the inspiration for this blog!!!

 Education is such an important part of not only the dysphagia eval, but also throughout therapy.  More than likely the patient/family will have no clue what dysphagia is or that such a condition even exists.  Swallowing is an event that you don’t think about.  Nobody swallows and analyzes their own swallow function (unless you’re an SLP of course).

 My first session with a patient is a large portion of education.  Whether I’m doing a swallow eval or a Modified Barium Swallow Study I’m continually educating.  I find that one of the easiest ways for me to educated patients/families is to explain each part of the eval and how it relates to swallowing.  If I’m checking for labial seal/strength I explain to the patient the purpose of the lips.  My new explanation for the tongue is that it’s like the quarterback of the team.  The tongue is the one that starts the play and makes it happen.  (The Colts have been doing well so everyone in Indiana loves football now.)  I not only educate on the structures and the means by which they function, I show pictures and try to demonstrate as best I can.

 When the patient understands the basics of such a complex and intricate system, they begin to understand how it could falter.  I always make sure that the patient understands that the swallow is something that we do so frequently we don’t even think about it.  I also let them know that the swallow involves a variety of closures, muscles, nerves and actions that all occur in 3-5 seconds.

 I typically have information available for the patient to take home with them.  I have brochures describing how speech therapy rehabs the swallow, information regarding swallowing and a self-test for dysphagia.  The self-test I use is found at  http://americandysphagianetwork.org.

 So, for all those that may read this and not understand dysphagia or know anything about the swallowing system:

 The lips are the first part of the swallowing system.  They have to close, and stay closed to help keep the food (the bolus) inside the mouth (the oral cavity).  The lip seal also helps create a pressure which helps to push the food (bolus) back and down the throat (the pharynx).  The tongue is the main player in the swallow.  The tongue is like the quarterback.  It is the first player to really receive the ball (the bolus), moves it around, getting it ready to “throw” down the line (the pharynx).  When the ball (bolus) is ready, the tongue takes it, throws it back (posterior propulsion) and launches the ball (bolus) down the pharynx.  Once the bolus starts down the pharynx, the airway has to move up and forward to close it off and you hold your breathe until the swallow is completed.  (I usually have the person swallow and feel their Adam’s Apple move up when they swallow.  If they can’t/don’t feel the laryngeal elevation, have them feel your throat.)  When the airway is closed, the food tube (esophagus) and lets the food go down.

 When we are not swallowing, our airway is open, allowing us to breathe and the esophagus is closed.  It switches for a split second when we swallow.  If any of these “tasks” don’t happen during the swallow or if they happen at the wrong time, that causes a problem with the swallow.

 Some of the problems that commonly occur with swallowing are lingual (tongue) weakness causing difficulty moving the bolus back in the mouth towards the pharynx (posterior propulsion), poor labial seal with food/drink falling out of the front of the mouth.  Pocketing is when food sticks in the mouth, usually between the cheeks and the gums.  If the airway doesn’t close off completely then food/liquids can start to go into the airway or go completely into the airway.  When the food/liquid goes into the airway, that is called aspiration and can lead to respiratory difficulties such as breathing difficulties, bronchitis, pneumonia or even death.

 Another problem that can occur in the pharynx is residue.  There are two pockets in your throat, one is called the valleculae and is located just above your airway.  The other is called the pyriform sinus and is above the esophagus.  If there is not enough pressure or force from the back of the tongue pushing the bolus down the throat and against the wall of the throat (posterior pharyngeal wall), the food can stick in these pockets after the swallow.  When food/drinks remain in the pharynx, the person may aspirate (the food/drink goes into the lungs) the residue once they breathe again.

 Another major part of the swallow that can “go wrong” is that the esophagus doesn’t open, or doesn’t open enough for the entire bolus to enter the esophagus.  The esophagus (upper esophageal sphincter-UES) is opened by the upward and forward movement of the airway (hyoid/larynx) and the pressure of the bolus.  Typically when the UES opening is compromised, the person will have pyriform residue, which may then be aspirated.

 There are many techniques/therapies to aid in rehabilitating the swallow mechanism.  Most commonly, people are placed on altered diets, or taught compensations such as chin tuck or head turn to stop aspiration/residue.  These alterations/compensations DO NOT improve the swallow, but may serve to eliminate the aspiration or risk of aspiration.  Swallowing is a muscle based system, powered by 6 cranial nerves.  We have to take an exercise physiology approach to rehabilitate dysphagia.  We can learn much from our physical and occupational therapy counterparts.  To train a person to walk, they have the person walk.  They may have them use a walker, but the ultimate goal is to have them walk without the walker or with independence.  The walker makes the person safe at the time, but does not “fix” the problem.  By the same token, we may put a person on an altered diet, or say, honey thick liquids.  This makes the person safe at the time, but does not “fix” the problem.  We work on strengthening those swallowing muscles to allow the person the opportunity to swallow with independence and to again swallow thin liquids.  Just as the physical therapist will work with the person walking without the walker in therapy, although outside of therapy the patient will probably still need to use the walker, we need to work with our dysphagia patient on swallowing thin liquids in therapy.  This may be a teaspoon of the liquid at a time.  By using the thin liquid, a little at a time, you are training the person to swallow.  You may use techniques such as the Mendelsohn or the effortful swallow to strengthen the muscles through resistance.

 I use VitalStim or neuromuscular electrical stimulation during swallowing therapy.  I place the electrodes so that they stimulate the impaired muscles during swallowing therapy.  If the person has decreased laryngeal elevation or the airway doesn’t close during the swallow, then I target the muscles that elevate the larynx.  The tongue is attached, via muscles, to the hyoid bone, which is part of laryngeal elevation.  So take the patient with decreased laryngeal elevation.  This person has aspiration with thin liquids but is safe with nectar thick liquids.  When using the Mendelsohn maneuver, the patient was able to safely swallow 5 ml of thin liquids.

 My therapy session would look like this:

At home, the person is drinking nectar thick liquids.  In therapy, I’m going to place the VitalStim electrodes on the laryngeal excursion muscles.  I like circuit therapy, I say it’s like Curves but for swallowing.  The patient will complete all exercises/swallows while the VitalStim is on.  We do lingual strengthening exercises using a tongue depressor (the patient pushes their tongue out, up and side to side against the tongue depressor), practice the Mendelsohn maneuver using dry swallows, when they are able to complete the Mendelsohn I would have them start using the Mendelsohn with 1ml water, working up to 5ml of water.  Therapy should always have many opportunities for swallowing (you can only exercise the swallowing system by swallowing).

 Vitalstim electrodes are attached to patient and VitalStim is turned on to a therapeutic level.

5 minutes of dry swallows using the Mendelsohn

4 minutes push your tongue out against the tongue depressor

5 minutes suck pudding through a straw (my FAVORITE exercise)

4 minutes push your tongue up against the tongue depressor

5 minutes pull your tongue back as far as it will go in your mouth, hold 5 seconds

4 minutes push your tongue to the right against the tongue depressor

5 minutes dry swallow using an effortful swallow

4 minutes push your tongue to the left against the tongue depressor

5 minutes pudding through the straw

5 minutes pretend to yawn and hold tongue back for a count to 5

5 minutes swallow pudding using an effortful swallow

 Now, keep in mind, the tongue is the quarterback of the swallow.  It is attached to the hyoid via muscles.  The person needs their larynx to elevate so I’m going to work on strengthening the tongue, to strengthen the hyolaryngeal excursion.  The Mendelsohn provides hyolaryngeal excursion through resistance of gravity.  The effortful swallow has been found to strengthen the overall swallow.  Tongue base retraction is part of the tongue which is going to aid in the hyolaryngeal excursion.  I like the pudding through the straw (I start with a regular straw and work to a coffee stirrer, my way of adding “weight” to the exercise) because it strengthens labial seal, the buccal (cheek) muscles, works on tongue base retraction, the person has a bolus to manipulate and then they have to swallow.  The pudding through a straw offers resistance to the oral phase of the swallow, by adding an effortful swallow, you add resistance to the pharyngeal phase as well.

 Keeping in mind the basic anatomy and physiology of the swallow, it just makes sense that exercise should offer resistance, making the task more difficult or require more effort.  Just as if you are trying to build up your arms to look good in your tank tops, you don’t start at 5 pounds and stay there.  You eventually add weight and keep working up.  Swallowing therapy should offer resistance, strengthening and endurance because you are working to improve the timing, speed and strength of the swallowing mechanism.